An investigation by EHI Primary Care has revealed that N3, the networking backbone for the National Programme for IT, is failing to provide the speed of service GP practices feel they need to carry out their work efficiently and effectively.
Without high-speed N3, many GP practices say they will struggle to run the applications being delivered by NHS Connecting for Health. GPs have told EHI Primary Care that slow connection speeds are already affecting Choose and Book and the problem is set to grow as other CfH applications such as the electronic prescription service, GP2GP record transfer and the NHS Care Records Service come on stream.
Part of the problem is being attributed to lack of bandwidth, with most practices only funded for 1Mb through Asymmetric Digital Subscriber Lines (ADSL). The problems are compounded because the cost of buying additional bandwidth from BT is unaffordable for primary care trusts.
Among those affected are the practices of leading GP IT representatives including Dr Paul Cundy, co-chair of the joint RCGP and GPC IT committee and his former co-chair Dr Alan Hassey. Dr Cundy said: “We are aware of this as a problem and in my own surgery it can sometimes be impossibly slow. Browsing the web for medical resources at midday is just a joke.”
"When you perhaps have seven minutes for the actual consultation waiting 30-40 seconds for a hospital letter to come up could be very critical."
— Mick Brighton, general practice IT manager, North Yorkshire
The problem is particularly acute in England’s 2200 branch surgeries where the N3 connection via a virtual private network (VPN) connection to the main surgery means even opening attachments such as consultants’ letters or clinical photographs can be painfully slow.
Mick Brighton, IT manager at Dr Hassey’s practice in North Yorkshire said attachments could take up to 40 seconds to open in consultations at the practice’s branch surgery.
He added: “That might not seem a lot in absolute terms but when you perhaps have seven minutes for the actual consultation, waiting 30-40 seconds for a hospital letter to come up could be very critical.”
One N3 implementation manager told EHI Primary Care that the national Choose and Book team had investigated problems at a large practice in his area and told the primary care trust it would need to buy more bandwidth to have any hope of meeting its Choose and Book trajectory.
He added: “We have to hit our Choose and Book targets and people are getting the finger pointed at them which would be fine if we had a perfect technical environment but we don’t.”
The ADSL used by practices means speeds are different coming in to the practice and going out of the practice so that while a practice might have 1MB downstream, (which according to BT’s brochure only guarantees a downstream maximum throughput of around 500kbps) its speed for information going out to the web upstream is limited to 256kbps That means GP IT systems are slowing down when practices need to go on to the internet or use CfH applications through N3 such as Choose and Book and the Personal Demographics Service.
The VPN network means requests for information from the branch, such as scanned letters held at the main surgery, must go via N3 to the main surgery and then back to the branch via N3 again.
Mr Brighton said his practice had identified that when automatic updates were being carried out the machines could slow considerable, so that in some 10 minute periods at the branch surgery it would take 10 seconds from a key being pressed and the character appearing. The practice is trying to get round the problem by holding back updates to times when the doctors are not in surgery but this risks delays in implementing potentially critical security updates.
Problems from GP practices with branch surgeries are acknowledged in BT’s own brochure on its VPN solution for branch surgeries.
The brochure says: “N3 services use ADSL and are therefore provided with asymmetric bandwidth. This means that there is more bandwidth available for traffic entering the site than leaving it, which supports the traffic patterns for centrally hosted applications and web based services.
“However, this asymmetry may impact response times on unusually high local traffic demand between main and branch sites. If this situation occurs, customers are advised to monitor the performance of their connections on line, and if necessary, order an upgrade to support local traffic. Such upgrades will require local funding.”
Most PCTs, however, say they would find it impossible to find the money demanded by BT’s price list for extra bandwidth. PCTs report they have been quoted as much as £30,000 for a practice to upgrade from 1MB to 2MBs and £80,000 for a three-year contract to upgrade an out-of-hours centre from a 1MB to 10MB link.
These quotes compare to costs of as little as £100 a year for an 8MB link for a residential user and even £200 for an 8MB residential link with BT’s own home package.
"Complicated systems are being developed but without the necessary infrastructure to let them work"
— Dr Paul Molony, GP, Canterbury
One of the key differences between residential broadband and that provided by BT to NHS customers is that the BT NHS deal specified that bandwidth should be ‘uncontended.’ This means that instead of having shared lines between as many as a 100 users, as is the case with home broadband, the link is exclusive to the NHS customer.
However it is now being suggested that GP practices might be much better served with a small contention ratio, such 1:10 or even 1:20, as is commonly used in small business, combined with faster broadband speeds.
Dr Paul Molony, a GP in Canterbury and practice IT lead, argues that at least a 10MB connection is needed for a practice such as his own.
He adds: “A 1Mb connection may be fine for a single hander with a secretary and receptionist and nurse connected, but is wholly inadequate for a group practice with up to 10 doctors, four nurses, an HCA as well as related support staff.
"Complicated systems are being developed but without the necessary infrastructure to let them work. We are keen to develop GP2GP and EPS [the Electronic Prescription Service] and can see major benefits for patients, but cannot move forward.”
He says his current 1MB connection not only means use of Choose and Book and web browsing is slow but also the practice’s own IT system. He adds: “By connecting to the national spine, our clinical system slows down, and occasionally stops altogether. Disconnecting speeds up our IT enormously. This is because when connected to the national Spine, the clinical system regularly checks data through N3.”
However practices’ problems with the speed of their system are not attributed to N3 by NHS Connecting for Health. A statement issued to EHI Primary Care by CfH said that some issues are associated with the localised performance of certain applications.
The statement adds: “Whilst these are not network issues, but relate to the configuration of customer systems, N3SP is working closely with local IT staff, systems suppliers and NHS CFH deployment staff to remedy these issues. We are not aware of any issues regarding speed of connection that can be explained with reference to N3."
BT’s advice to customers wishing to increase their N3 access bandwidth is to upgrade to a 2MB Private Circuit which they say would deliver an eight-fold improvement in access speeds. The N3 provider does not, however, specify who would fund such an upgrade which would be outside the National Catalogue and therefore likely to fall into the lap of PCTs already facing severe financial constraints.
In February 2004 BT was awarded a £530 million contract to provide a broadband network to all NHS organisations.
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